OBSTETRICS-GYNECOLOGY II

CLINICAL ROTATION
Table of Contents • At 12 weeks, fundus is palpable on
I. Diagnosis of Pregnancy bimanual exam, the uterus has
A. Presumptive Evidence………………………………………………………... 1 become an abdominal origin
B. Probable Evidence……………………………………………………………. 1 Hegar’s sign • 6-8 weeks
C. Positive Signs…………………………………………………………………. 1 • Softening of the uterus isthmus
D. Eponym Signs…………………………………………………………………. 1
II. Prenatal Care
• Firm cervix now contrasts with
A. Frequency of Prenatal Check-up……………………………………………. 1 softer fundus and isthmus
B. Initial Prenatal Workup……………………………………………………….. 1 Goodell’s sign • 6-8 weeks
C. Vaccination…………………………………………………………………….. 2 • Softening of the cervix
D. Recommended Dietary Allowance………………………………………….. 2 Braxton Hicks • 28 weeks
E. 10 Danger Signs of Pregnancy……………………………………………… 2
F. OB Score………………………………………………………………………. 2
contractions • Painless, perceptible, not regular
G. Last Menstrual Period………………………………………………………… 2 • False contraction
H. Estimated Date of Confinement……………………………………………... 2 Physical outlining of
I. Trimesters……………………………………………………………………… 2 fetus
J. Quickening…………………………………………………………………….. 2 Ballottement •
Evident in the 2nd semester
III. Physical Examination
A. Fundal Height…………………………………………………………………. 2
Detection of B-hCG •
6 days after fertilization
B. Fetal Heart Tones…………………………………………………………….. 3 •
8-9 days post-implantation
C. Leopold’s Manuever………………………………………………………….. 3 •
Pregnancy test: positive at 12.5
D. Speculum, Pap Smear, Bimanual Exam…………………………………… 3 mlU/mL (very sensitive)
IV. Obstetrics Complications • Note that a positive pregnancy test is only a probable evidence
A. Hypertensive Disorders………………………………………………………. 3 of pregnancy. Rare causes of positive pregnancy test without
V. Labor and Delivery
A. Pelvimetry……………………………………………………………………… 4
pregnancy are:
B. Bishop Score…………………………………………………………………... 4 o Exogenous hCG injection
C. Medications for Labor………………………………………………………… 4 o Renal failure with impaired hCG clearance
VI. Family Management o Physiological pituitary hCG
A. LAM…………………………………………………………………………….. 5 o hCG-producing tumors (usually GI, ovarian, bladder, or
B. Vasectomy…………………………………………………………………….. 5 lung origin)
C. POP…………………………………………………………………………….. 5
D. Calendar……………………………………………………………………….. 5
Positive Signs

Diagnosis of Pregnancy Fetal Heart tone • Normal rate: 120-160 bpm

• Auscultation: as early as 16
Presumptive Signs and Symptoms of Pregnancy weeks
• Doppler ultrasound: 10 weeks
• TV-UTZ: 5 weeks
Morning Sickness • 6-18 weeks
Perception of fetal
• Peak of HCG: 8-10 weeks
movement by
• Plateau at 16 weeks examiner
Fatigue Sonographic • TV-UTZ: gestational sac by 4-5
Frequency in • 1st and 3rd trimester examination weeks AOG; yolk sac by 5 weeks
urination • Due to the increasing size of the • Early UTZ: done before 12 weeks
uterus AOG (most accurate aging tool)
Quickening • 16-20 weeks
Cessation of • Amenorrhea is not a reliable sign Eponym Signs
menses until 10 days or more after
expected menses
Isthmus Hegar’s Sign 6-8 Softening
Beading cervical • 6 weeks
weeks
mucus • Poor crystallization or beading is
Cervix Goodell’s Sign 4 weeks Softening due to
due to progesterone
edema
• Ferning: sign of increased
Vagina Chadwick’s 6 weeks Violaceous due to
estrogen which makes pregnancy Sign increased blood
unlikely. Ferning is also observed
as a result of amniotic fluid
leakage. Prenatal Care
Chadwick’s sign • 6 weeks
• Vaginal mucosa becomes dark- Frequency of Prenatal Check-Up
bluish red and congested • For Uncomplicated Pregnancy in clinical practice:
Changes in breast • 6-8 weeks o 1x/month: up to 28 weeks
• Engorgement starts o 2x/month: 28-35 weeks
Skin changes • Due to MSH o 1x/week: >35 weeks
o Chloasma/ Melasma: mask of • For Uncomplicated Pregnancy, WHO criteria of
pregnancy consultation:
o Linea nigra: darkening of linea o Once in the 1st trimester (up to 14 weeks)
alba o Once in the 2nd trimester (14-28 weeks)
• Striae gravidarum: due to collagen o Twice in the 3rd trimester (>28 weeks)
breakdown • For Complicated Pregnancy:
• Striae telangiectasia: due to o 2x/week for high risk pregnancy starting at 28 weeks
increased estrogen
Increased body • 6 weeks Initial Prenatal Workup
temperature • Due to increased progesterone • CBC with DC/PC
• Urinalysis (ideally urine GS/CS)
Probable Evidence • ABO blood typing; RH
• Fasting Blood Sugar (FBS) or HbA1c
Enlargement of • Starts at 6 weeks • Hepatitis B screening (HBsAG)
Abdomen • Rubella IgG

Transcribed by: Erikel Roldan Checked by: Abu Page 1 of 5

OBSTETRICS-GYNECOLOGY II Clinical Rotation

• VDRL, RPR
• ICC ELISA Calories • Increase 100-300 kcal/day
• Pap Smear Protein • 5-6 g/day
• 75g OGTT at 24-28 weeks AOG Iron • 27 mg elemental Fe/day
o Human Placental Lactogen (HPL) is produced during • 60-100 mg if large, twins, started late,
the 24-28th week. irregular, or decreased haemoglobin
o It has a growth hormone-like action and causes insulin • Start giving at 2nd trimester (avoid vomiting
resistance, lipolysis, and increased fatty acids. which peaks during the 1st trimester)
o Especially if with strong family history of gestational Folic Acid • 400 mcg
diabetes or macrosomia • 4mg if with history of neural tube defects
• Baseline Ultrasound • Start giving preconception until 1st trimester
o Transvaginal US: 1st trimester
o Pelvic US: >13 weeks
• Folic acid: intake for 3 months prior pregnancy and continued
• Biometry +/- BPP at 24-28 weeks AOG for 3 months during pregnancy
o BPP is done at 24-28 weeks AOG because pregnancies
• Ferrous Sulfate: can cause vomiting, so it is usually given
with severe complications require early testing.
during the 2nd trimester when the hCG levels have already
o In general, testing begins at 32-34 weeks AOG
decreased, unless if with bleeding tendencies
o At less than 24 weeks AOG, the examiner might not be
• Multivitamins: only recommended if without vomiting
able to appreciate well all the components of the BPP.
o Biometry can be done anytime • If patient persistently vomits:
o BPP is usually used to monitor patients that are post- o Withhold Iron
dated (>40 weeks), a score of 8/8 indicates very minimal o Small frequent feedings
risk of fetal mortality and pregnancy could be extended o Avoid fatty foods
for one more week. (could be extended up to 42 weeks, o Give ginger
but must be reassessed every week) o Give Ice chips
o Reactive Fetal Heart Rate also known as the Non Stress o Vitamin B complex: reduces vomiting
test is not usually done = Modified BPS
10 Danger Signs of Pregnancy
Signs of Preeclampsia
• Headache
• Blurring of vision
• Prolonged vomiting
• Epigastric/RUQ pain
• Nondependent edema
Signs of Infection like UTI, which may cause PROM
• Fever
• Dysuria
• Watery vaginal discharge

Signs of Threatened Pregnancy

• Bloody vaginal discharge
• Decreased fetal movement

OB Score: GP (TPAL)
Vaccinations for Pregnant Mothers
• Gravida-Para (Term - Preterm- Abortuses – Living Children)
RECOMMENDED: • Gravity
TD • Could be given at any trimester o Number of pregnancies irrespective of the outcome
• Given at 0, 1, 6 months o Including abortion, H. mole, etc. (basta nagkalaman ang
TDAP • Given at 28-36 weeks uterus ni mommy)
Flu vaccine • Given on 2nd or 3rd trimester for • Parity
pregnancies occurring during the flu o Number of pregnancies that reached 20 weeks
season (October-March) o Mga pinanganak ng >5 months or >20 weeks
Hepa A and Hepa • Could be given but not routinely o Not increased if multiple pregnancy (if twins or triplets
B or more, 1 lang ang parity, TPAL ang mababago)
Pneumoccocal • Recommended for high risk patients o Not decreased by stillbirths (kahit di living yung bata,
(ex. HIV) basta umabot ng 20 weeks or more, kasali sa parity)
• Term
• Live attenuated vaccines such as MMR and BCG are not o All pregnancies that reached 37-42 weeks AOG
recommended during pregnancy o Kahit hindi living, basta umabot ng 37, included na sa
o Pregnancy should be avoided for 12 weeks after MMR term
vaccination • Preterm
o Could be given AFTER pregnancy o Pregnancies that are <37 weeks but >20 weeks (20-36
• HPV could be given after pregnancy for mothers aged less than weeks AOG)
26 years old o If sinabi na “nalaglag” pero >20 weeks na, considered
as preterm already, tapos bawas sa living
• Most teratogenic before 12 weeks: German Measles (Rubella) • Abortion
o Embryonic period: the first 8 weeks is considered as the o Pregnancies that are <20 weeks or <5 months or <500
stage of organ formation which has the highest risk for grams
insult o Twin abortion is counted as 1 in A of TPAL
o Fetal Period: > 9 weeks, start of the skeletal and muscle o Including H. mole
growth • Living
• Most teratogenic during the third trimester: Chicken pox o Number of children that are living regardless if term or
(Varicella) preterm

Recommended Dietary Allowances (RDA) Examples (given by Dra. De Vera)

✓ Hx: 6 months pregnant, a year ago - IUFD (Intrauterine
• Dietary Fe and Iodine are not enough to supply pregnancy
fetal death)
• With potential toxic effects include: Fe, Zn, Se, Vitamin A, B6, ✓ 1 abortion
C, D (>10,000 IU Vitamin A per day may be teratogenic)
✓ pregnant today
• Twice the amount of RDA should be avoided

Transcribed by: Erikel Roldan Checked by: Abu Page 2 of 5

OBSTETRICS-GYNECOLOGY II Clinical Rotation

o G3P1(0110) o Almost 100% by 10 weeks

• Stethoscope
✓ Hx: 1 abortion o As early as 16 weeks
✓ 1 twin o 80% at 20 weeks
✓ pregnant today o 100% at 22 weeks
o G3P1(1012) o On fetal back, use bell: 12-14 weeks
o *Twin pregnancy is counted as 1 in term o To confirm if fetal heart, compare with the pulse of the
mother (Mother NV: 60-100 bpm)
✓ 5x nabuntis
✓ 1 ectopic Leopold’s Maneuver
✓ 1 abortion
✓ 3 live children (full term) L1: Fundal Grip
o G5P3(3023)
o *Ectopic is counted under Abortion • What fetal pole occupies the fundus?
o Irregular, nodular = Feet = Cephalic Presentation
o Hard, round, ballotable, mobile = Head = Breech
Last Menstrual Period Presentation
• For the computation of Age of Gestation (AOG) o Almost 100% by 10 weeks
• Must be the first day of the last menstrual period
• Also ask for the previous menstrual period (PMP) to confirm if L2: Umbilical Grip
regular or irregular • On which side is the back? (maternal left or maternal right)
• If irregular: record the shortest and longest cycle o Linear, convex, bony ridge = Back
• Example: (from 2nd year trans) o Numerous nodulations = Extremities
LMP – February 14, 2016
Date of Visit (Check-up) – August 3, 2016 L3: Pawlick’s Grip
Feb (29 - 14) = 15 • What fetal part lies above the pelvic inlet?
Mar = 31 o Head engaged = feel shoulder, fixed, knob-like
Apr = 30 o Head not engaged = feel round, ballotable mass
May = 31
June = 30 L4: Pelvic Grip
July = 31
Aug = 03 • On which side is the cephalic prominence?
= 171 days / 7 = 24.43 o Opposite side as the back = Head flexed
= 0.43*7 to get days = 3 o Same side as the back = Head extended
= AOG is 24 weeks and 3 days • Engaged or not?
• Most accurate for recording the AOG is the transvaginal o Engaged = Hands are parallel and does not meet
ultrasound (first trimester- crown lump length) o Not engaged = Hands converge
o Margin of error of +/-3 days
o If difference of AOG computed using the LMP and the Speculum Exam, Pap Smear, and Bimanual Exam
AOG through TV US is >3 days, follow US *Sa part na to ang tinanong lang ni doc kung ano yung mga parts
ng internal examination tsaka kung ano yung mga inoobserve, di
Estimated Date of Confinement naman nya sinabi na tandaan yung step by step.
• Naegele’s Rule
Preparation
• If LMP is April- December:
o -3 months, +7 days, +1 year • Wash hands
• If LMP is January- March: • Counsel patient as to the examination
o +9 months, +7 days • Check that instruments and supplies are available
• Reflects 40 weeks of pregnancy • Properly drape the patient
o Inform patient of possibility of giving birth 3 weeks prior • Turn on the droplight
to EDC (37 weeks- considered as term) • Put on gloves properly

Trimesters Inspect and Palpate

• 1st trimester: until 14 weeks AOG • Inspect and palpate the following:
• 2nd trimester: 15 weeks- 28 weeks AOG o Labia
o Clitoris
• 3rd trimester: 29 weeks – 42 weeks AOG
o Perineum
o Skene’s glands
Quickening or Fetal Movement o Urethra
• If primigravid: 18-20 weeks AOG • REPORT: Normal external genitalia (normal labia, clitoris, and
• If multigravida: 16-18 weeks AOG perineum). No lesions, masses, and pigmentations.

Physical Examination Speculum Exam

• Inform the patient regarding the step.
Fundal Height • Wash the speculum to lubricate. Use the proper size.
• At 12 weeks AOG, the uterus becomes an abdominal organ • Apply downward pressure on the introitus to relax the vagina
• At 16 weeks AOG, the fundus is midway between the pubis • Insert the speculum on a 45-degree angle and open the blades
symphysis and the umbilicus fully after the cervix has been identified
• At 20 weeks AOG, the fundus should be at the level of the • When inserting speculum, initially it should be perpendicular to
umbilicus the vaginal wall, then increase to 45 degrees (45 degrees is
• Ideally, bladder must be rained first. the largest angle of the vaginal canal)
• Measure fundal height if it is above the level of the umbilicus • Inspect the vaginal canal (check for vaginal discharge).
• Between 20-34 weeks, fundus (in cm) correlates closely with • Inspect the cervix and the os (opening) (note color, position,
AOG smoothness, and presence or absence of discharge, check for
• Measure starts with minus 1 cm masses).
• Measure from the superior order of the symphysis up to the • REPORT: The vagina is pink. There are no apparent masses
palpable fundus or discharge. The cervix is also pink/ violaceous. There is also
no apparent masses or discharge.
Fetal Heart Tones Pap Smear
• Doppler • Carefully collect specimen from the ectocervix and endocervix
o As early as 8 weeks

Transcribed by: Erikel Roldan Checked by: Abu Page 3 of 5

OBSTETRICS-GYNECOLOGY II Clinical Rotation

• Properly apply swabs to a previously labelled slide Preeclampsia • New onset proteinuria (no proteinuria at <20
• Fix the specimen using 95% ethanol superimposed weeks AOG), or
• Inform the patient that the speculum will be removed on Chronic • Sudden increase in proteinuria or in BP (if
• Unlock the speculum and slowly withdraw the speculum while Hypertension already with proteinuria at <20 weeks AOG),
closing the blades or
• Thrombocytopenia (If with proteinuria at <20
Bimanual Examination weeks AOG)
• Insert fingers properly
• Describe the: Blood Pressure in Pregnancy
o External genitalia • Usually decreases during the second and early third trimesters
o Vagina • Late third trimester: BP returns to normal (difficult to distinguish
o Cervix: size and consistency whether hypertension is chronic or is due to pregnancy if
• Palpate the uterus and describe the: patient was not seen <20 weeks)
o Size, shape, location, consistency, mobility, and
tenderness HELLP Syndrome
• Palpate the adnexa and describe: • A complication of hypertensive disorders in pregnancy
o Ovaries: size, mobility, consistency, tenderness, and • Indication for Caesarean section
presence of mass • Components of the syndrome:
• REPORT: Normal external genitalia. The vagina is smooth and o Hemolysis: LDH >600 IU/L
parous. The cervix is smooth, 3x3 cm, closed, and non-tender. o Elevated Liver enzymes: AST/ALT >2x the baseline
The uterus is small/enlarged to AOG, non-tender. No adnexal elevated
mass or tenderness. o Low Platelet count: <100,000/uL
• Partial HELLP syndrome: 2 out of 3 criteria
Rectovaginal Examination • Complete HELLP syndrome: 3 out of 3 criteria
• Slowly insert the middle examination finger into the rectum with
the index finger in the vaginal canal Labor and Delivery
• Check for tenderness or masses in the cul-de-sac and *For this part, madaming under nito, ang ilalagay ko lang yung
parametria mga binanggit nila doc kasi sabi naman nila prenatal care yung
• Explain findings to the patient written exam.
• REPORT: Good sphincter tone. Intact rectal vault. No
intraluminal mass. Rectovaginal septum is intact. Parametria Pelvic Planes
is soft, thin, smooth, pliable, with no masses. There is no
fullness on the cul-de-sac. No blood per examining finger. *Tinuro lang ulit ni doc kung pano kuhanin yung mga pelvic
planes (not sure if kasama sa practical exam)
*Mas detailed and complete discussion including yung ibang
Obstetrics Complications under ng pelvimetry sa 2nd year trans, Module 4, Lecture 3
*Hypertension lang yung laging tinatanong nila doc, though
madami pang ibang OB complications, kayo na lang maghanap Pelvic Inlet
nung iba pa.
• Superior strait
• 3 anteroposterior diameters:
*Di ko na rin ilalagay lahat nung details, and lagi lang naman
o Diagonal Conjugate
tinatanong nila doc yung diagnosis. If you want to read further,
- Landmarks: Inferior part of symphysis pubis &
may trans tayo for HPN sa module 1, lecture 1.
sacral promontory
- Can be directly measured
Hypertensive Disorders o Obstetric Conjugate
• Complicates 5-10% of all pregnancies - Cannot be measured directly
• One of the deadly triad (with haemorrhage and infection) - Obstetric conjugate = Diagonal Conjugate - 2
1. Hypertensive disorders – 16% maternal mortality o True Conjugate
2. Hemorrhage – 13% - Not clinically significant so it is not measured
3. Infection (Abortion – 8%, sepsis – 2%)

Diagnosis of the four types of Hypertensive Disease

Gestational • BP of ≥ to 140/90 after 20 weeks AOG (mid-

Hypertension pregnancy) in previously normotensive
women
• No evidence of preeclampsia (ex. No
proteinuria)
• Hypertension resolves 12 weeks
postpartum
Preeclampsia • BP of ≥ to 140/90 after 20 weeks AOG (mid-
and pregnancy) in previously normotensive
eclampsia women
syndrome • Proteinuria
o ≥ 300 mg/24h, or
o Protein: creatinine ratio of ≥ to 0.3, or
o Dipstick 1+ persistent Pelvic Outlet
• Or • Inferior strait
o Thrombocytopenia: <100,000/uL • Landmarks: 2 triangles
o Renal insufficiency: Crea >1.1dL or o Posterior or Anal triangle: tip of sacrum and 2 ischial
2x the baseline tuberosities
o Liver involvement: AST, ALT of 2x the o Anterior or Urogenital triangle: descending inferior rami
baseline of the pubic bones and 2 ischial tuberosities
o Cerebral symptoms: Headache, • Adequate measurement: should be 90-100 degrees upon
visual disturbances, convulsions estimation of subpelvic angle and a fist should fit between the
o Pulmonary edema distance of intertuberous diameter
Chronic • BP ≥ 140/90 before 20 weeks AOG, and
hypertension • BP ≥ 140/90, 12 weeks postpartum
of any
etiology

Transcribed by: Erikel Roldan Checked by: Abu Page 4 of 5

OBSTETRICS-GYNECOLOGY II Clinical Rotation

Medications during Labor

Magnesium Sulfate
• Used as an anti-convulsant
• Prevents seizure and used for fetal neural protection
• Dosages:
o 1-2g/hr IV drip
o 4g slow IV in 20 mins, or
o 5g IM for each buttock
• Monitor:
o Respiratory depression: <12/min
o Patellar reflex: < +2
o Urine output: < 30cc/hr
• If toxicity occurs:
o Give Ca gluconate Ig IV
Midpelvis
• Least pelvic dimension Nifedipine
• Landmarks: • Used as tocolytics
o 2 Ischial spines - non-prominent; most important • Given to complete dexamethasone dosage
o Sacrum - well-curved
o Pelvic side walls - divergent Dexamethasone
o Sacrosciatic notch – wide • 6 mg every 12 hours, for 4 doses
• The midplane is contracted if there is a prominent ischial • Given between 34-36 weeks AOG
spine, flattened sacrum, converging pelvic side walls and
narrowed sacrosciatic notch. Betamethasone
• 12 mg every 24 hours, for 2 doses
• Given between 34-36 weeks AOG

Family Management
*Complete lecture about family planning on second year trans
module 6 lecture 2.

Lactation Amenorrhea (LAM)

• Criteria:
o Exclusively breastfeeding (no other intake aside from
breast milk) for 6-7x per day
o Menses has not returned
o <6 months postpartum

Great Pelvic Dimension Vasectomy

• No obstetrical significance
• Needs 2x ejaculation or at least 3 months after the procedure
with sperm analysis confirming 0 sperm count
NORMAL PELVIMETRY
Progestin Only Pills
Pubic arch >90 Ischial spines Blunt
Diagonal >11.5 Sidewall Parallel • Could be taken at 6 weeks postpartum
conjugate • Safe for breastfeeding mothers
Bituberous >8.5 Sacral inclination Posterior • Oral contraceptives are not used for lactating mother because
diameter it decreases milk production
Bispinous >9.5 Sacral notches Wide
diameter Calendar/ Rhythm Method
Coccyx Movable Sacral width Wide • Get the shortest and the longest cycle for the last 6 months
Sacral curvature Hollow • Subtract the shortest cycle with 18; then subtract the longest
cycle with 11
Bishop Score • EXAMPLE: shortest cycle 28 days, longest cycle 30 days
28 -18 = 10 days
30 - 11 = 21 days
Day 10 to 21 of the cycle is not a safe period and should avoid
sexual intercourse
• If always 28 days, note safe: 12-16 days

REFERENCES:
• Discussions of Dra. De Vera
• Powerpoint: OB Clinics Orientation
• Villafuerte and Villafuerte, OB-GYNE
Gold, 2nd Ed.
• 2nd year transes batch 2019: 4.3, 6.2
• 3rd year transes batch 2019: 1.1

*Guys, ito lang po yung mga diniscuss ni Doc De Vera nung

orientation natin for OB clinic and during mga recitations, nilagay
ko na lang din yung mga sabi nila na hanapin sa book. Pero
basahin nyo pa rin yung book kung madami pa kayong time, use
this as guide lang. Thank you!

Transcribed by: Erikel Roldan Checked by: Abu Page 5 of 5